YOU MAY BE ELIGIBLE TO RECEIVE FREE OR DISCOUNTED CARE.

Completing this application will help DRH Health determine if you may be eligible for free or discounted services or other public programs that can help you pay for your healthcare.

INSTRUCTIONS FOR COMPLETING THIS FORM:

Please fill this form out completely and return with all required documentation. Financial assistance will not be awarded to those who do not complete the application process, including the requirement for the patient to apply for programs for which they may qualify (i.e. Medicaid).

Please submit this application with the following documentation:

1. Copies of your current federal tax return with all schedules (including W-2s) or Proof of Non Filing (IRS Form 4506)
2. Household income verification as required below in the “Household Monthly Income” section
3. Proof of Medicaid denial, if eligible — apply at http://www.okhca.org/individuals.aspx (Online Enrollment)

Financial Assistance Application

Patient Name:

First Middle Last

Date of Birth

MM slash DD slash YYYY

Account #

Responsible Party/Guarantor Name

First Last

Guarantor Date of Birth

MM slash DD slash YYYY

Social Security Number

Relationship to Patient

Home Phone

Cell Phone

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Own/Rent

Own

Rent

Employer Name

First Last

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Work Phone

Spouse Name

First Middle Last

Spouse's Date of Birth

MM slash DD slash YYYY

Spouse's Social Security Number

Additonal Household Members

Name

First Last

Date

MM slash DD slash YYYY

Relationship to Patient

Name

First Last

Date

MM slash DD slash YYYY

Relationship to Patient

Other Information

Does your employer (or spouse's employer) offer group health insurance?

Yes

No

If Yes, please list insurance company below

Insurance Company

Do you have other types of insurance that may pay medical bills?

Yes

No

If Yes, please list insurance company below

Insurance Company

Do you have a Health Savings/Flex Spending Account?

Yes

No

If Yes, please list the balance amount below

Balance of Health Savings Account

Does your employer reimburse you for any deductible or healthcare costs?

Yes

No

Were you denied for Medicaid?

Yes

No

If yes, please attach copy of Medicaid Denial

Max. file size: 300 MB.

Are you eligible for COBRA through a previous employer?

Yes

No

If yes, please list insurance company below.

Was the patient involved in an alleged accident that led to the need for services?

Yes

No

Was the patient a victim of an alleged crime that led to the need for services?

Yes

No

Household Monthly Income

Employment Income (Gross)

Responsible Party

Spouse

 

Add Remove

Provide a paycheck stub for the last two pay periods or three months of bank statements.

Self Employment Income (Gross)

Responsible Party

Spouse

 

Add Remove

Provide three months bank statements

Pension, Retirement, Social Security Income

Responsible Party

Spouse

 

Add Remove

Provide your Pension?Retirments statements and/or Social Security award letter

Umemployment, Disability Income

Responsible Party

Spouse

 

Add Remove

Provide unemployment, disability award letter, or three months bank statements

Child Support, Alimony

Responsible Party

Spouse

 

Add Remove

Provide a copy of your divorce decree, legal separation notice, or custody agreement

Other (Please list source)

Responsible Party

Spouse

 

Add Remove

Provide three months bank statements with an explanation of your income source(s)

Other Income Source

Upload files here

Max. file size: 300 MB.

Assets

Assets

Cash

Financial Institution

Total balance (approximate as accurately as possible)

 

Add Remove

Assets

Checking Account(s)*

Financial Institution

Total balance (approximate as accurately as possible)

 

Add Remove

Assets

Savings Account(s)*

Financial Institution

Total balance (approximate as accurately as possible)

 

Add Remove

Assets

Stocks or Bonds*

Financial Institution

Total balance (approximate as accurately as possible)

 

Add Remove

*Please provide three months bank statements or Stock/Bonds statements

Max. file size: 300 MB.

Please explain any situation we should be informed of in order to understand your inability to pay the medical balance.

Additional verification may be required.

Consent(Required)

Please check if you agree with the statement below

I hereby state that the information given herein is true and correct. I authorize any required verification, including a credit bureau report. I understand that if this information is determined to be false or deceptive, I will be liable for payment of charges for all services rendered. I understand that this request for financial assistance may not pertain to other health care providers.

Responsible Party Signature(Required)

Date Signed

MM slash DD slash YYYY